Medical care in association with procedures, medications, laboratory tests, evaluations, treatments, and assessments performed for a patient is oftentimes electronically documented by healthcare providers. In an electronic healthcare environment, a documentation section for recording medical data associated with a specific medical event is established by a healthcare provider around the time of a medical event for which documentation is desired. Additional documentation sections are also established by the healthcare provider upon the occurrence of or in advance of subsequent medical events. Accordingly, the healthcare provider is required to independently create a documentation section for each medical event. That is, for each documentation section, the healthcare provide must specify the data elements desired to be included therein. As such, each documentation section might have varied data elements and/or a varied numbers of data elements even though the documentation sections are associated with a common medical category (e.g., drains and tubes). In addition, each documentation section is provided with a nonspecific label.
Such an individual creation of a documentation section is both time-consuming and error prone. For example, specifying data elements for inclusion within each new documentation section is inefficient in that it requires the healthcare provider to duplicate efforts in creating multiple documentation sections. In addition, such varied documentation sections can prevent or hinder the ability to group documentation sections, or portions thereof, and/or analyze or trend data provided within the documentation sections. Further, such nonspecific labels can provide confusion and even cause healthcare providers to commit errors in providing medical care.
Thus, it would be beneficial to have a system and method in an electronic healthcare environment that allows documentation sections to be efficiently repeated so that a healthcare provider can easily document medical data associated with care provided to a patient. Such duplicated documentation sections would also enable an enhanced analysis of the medical data provided within multiple documentation sections. Further, descriptive labels for each documentation section can provide valuable information that is easily accessible to healthcare providers.